Bilateral Tibial Tuberosity Periosteal Sleeve Fracture in an Adolescent: A Case Report.

Tibial tuberosity avulsion fracture is a rare injury, and bilateral occurrence is more uncommon. Periosteal sleeve fracture is a unique fracture pattern which was first described in the lower pole of patella in children. We are reporting a rare case of bilateral tibial tuberosity sleeve fracture in a teenage boy which occurred while sprinting. The patient underwent open reduction, pull through suture fixation of the bilateral tibial tuberosity and screw fixation of left tibial tuberosity. Post-operative rehabilitation included gradual increment of range of motion with hinged brace and quadriceps muscle strengthening. Close follow-up was done to monitor the progression of his recovery. At six months follow-up, the patient recovered well. Both knees had full range of motion with an intact extensor mechanism.

Walking further. How surgery can help the cerebral palsy child.

INTRODUCTION: The prevalence of cerebral palsy (CP) in Malaysia is estimated at 2.6 per 1000 live births which is comparable to that of Australian and European data with ranges of 2.3- 4.21,2. Surgical intervention for the improvement of gait function and mobility in CP is a common practice, however scarce literature of its outcomes is available in Southeast Asia. This paper aims to address and compare outcomes of surgical interventions in our centre with other countries. MATERIAL AND METHODS: Patients with Spastic CP with Gross Motor Function Classification System (GMFCS) I-III that underwent lower limb surgical intervention in our centre from 2008-2018 were retrospectively reviewed for The Spinal Alignment and Range of Motion Measure ROM subscale (SAROMM) scores and Functional Mobility Scale (FMS) 18 months after surgery. Changes in SAROMM, FMS scores and minimal clinically important difference (MCID) were determined. RESULTS: 19 patients were included in the study with mean age of 12.58. All patients underwent muscle tendon procedures. Box plot analysis of SAROMM showed reduction of median scores at 6(26.3%) and 12(47.4%) months which plateaus at 18 months post-surgery. Repeated measure ANOVA analysis showed there was a statistically significant effect of time on SAROMM scores (p <0.001) with MCID of 13.4. Improvement of FMS scores was the most at 50m with 13 children (p < 0.05), one at 5m and five at 500m. None reported worsening of FMS scores at 18 months. There were no changes of GMFCS levels by the end of 18 months. CONCLUSION: Surgeries performed on GMFCS I-III patients with the aim of gait improvement translates into improved mobility with results comparable to other countries.

The Osseous Pathology of Purpura Fulminans in a Two-Year-Old Child: A Case Report.

Purpura fulminans (PF) is a severe clinical manifestation of Neisseria meningitides infection that is associated with high mortality rates in children. Survivors are frequently left with debilitating musculoskeletal sequelae. There is a paucity of reports on the musculoskeletal pathology of purpura fulminans. We report on a 2-year-old boy with purpura fulminans due to meningococcemia. The child developed distal gangrene in both the upper and lower limbs. Amputations were done for both lower limbs. Histological examination of the amputated specimens showed an inflammatory process and features of osteonecrosis. The latest follow-up at the age of 6 years showed a right knee valgus due to asymmetrical growth arrest of the proximal tibia. PF and its complications are challenging to treat and may require a multidisciplinary approach to improve patient's functional ability.

Toe Macrodactyly, Macrodystrophia Lipomatosa, Fibrolipomatous Hamartoma and Lipomatosis of Nerve. Are they similar?: A Case Report.

Macrodystrophia Lipomatosa (MDL) of the toe is a rare, congenital, disproportionate overgrowth involving one or more digits in the lower limb. Despite being a benign condition, when left untreated, it may cause physical impairment and interfere with daily activities. This form of localised gigantism is the result of excessive proliferation of fibroadipose tissue within the nerve along with associated macrodactyly. The mainstay of treatment is debulking or amputation to accommodate the patient's daily activities, as well as for cosmesis. In this case report, the clinical and radiographic findings, anatomical descriptions, and histopathological findings are presented. The difference between MDL, fibrolipomatous hamartoma (FLH) and lipomatosis of the nerve (LON) are also discussed.

Classification of Alzheimer's Disease Using Ensemble of Deep Neural Networks Trained Through Transfer Learning.

Alzheimer's disease (AD) is one of the deadliest neurodegenerative diseases ailing the elderly population all over the world. An ensemble of Deep learning (DL) models can learn highly complicated patterns from MRI scans for the detection of AD by utilizing diverse solutions. In this work, we propose a computationally efficient, DL-architecture agnostic, ensemble of deep neural networks, named 'Deep Transfer Ensemble (DTE)' trained using transfer learning for the classification of AD. DTE leverages the complementary feature views and diversity introduced by many different locally optimum solutions reached by individual networks through the randomization of hyper-parameters. DTE achieves an accuracy of 99.05% and 85.27% on two independent splits of the large dataset for cognitively normal (NC) vs AD classification task. For the task of mild cognitive impairment (MCI) vs AD classification, DTE achieves 98.71% and 83.11% respectively on the two independent splits. It also performs reasonable on a small dataset consisting of only 50 samples per class. It achieved a maximum accuracy of 85% for NC vs AD on the small dataset. It also outperformed snapshot ensembles along with several other existing deep models from similar kind of previous works by other researchers.

Angular Deformities of the Knee in Children Treated with Guided Growth.

INTRODUCTION: The guided growth technique is an alternative to corrective osteotomy for treating angular deformities of the extremities. It has the advantage of being minimally invasive and is effective in a growing child. This study reports on the outcome of guided growth technique using a plate in correcting knee angular deformities. MATERIAL AND METHODS: We conducted a retrospective study of children with angular deformity of the knee treated by the guided growth technique from January 2010 to December 2015 in a tertiary centre. The guided growth technique was done using either the flexible titanium plate (8-plate) or the 2-hole reconstruction plate. Correction of deformity was assessed on radiographs by evaluating the mechanical axis deviation and tibiofemoral angle. The implants were removed once deformity correction was achieved. RESULTS: A total of 17 patients (27 knees) were evaluated. Twenty-two knees (81.5%) achieved complete correction of the deformity. The median age was 4.0 (interquartile range 3.0-6.0) years and the median Body Mass Index (BMI) was 26.0 (25.0-28.0). There were 7 unilateral and 10 bilateral deformities with different pathologies (14 tibia vara, 3 genu valgus). The median rate of correction was 0.71° per month. One patient (1 knee) had screw pull-out and two patients (4 knees) had broken screws in the proximal tibia. Three patients (5 knees) failed to achieve complete correction and were subsequently treated with corrective osteotomies. Out of five patients (8 knees) who were followed-up for at least 12 months after removal of hardware, two had rebound deformities. No permanent growth retardation occurred in our patients. CONCLUSION: Our outcome for guided growth to correct knee angular deformity was similar to other studies. Guided growth is safe to perform in children below 12 years old and has good outcome in idiopathic genu valgus and Langeskiold II for tibia vara. Patients should be observed for recurrence until skeletal maturity following implant removal.

Anxiety Reaction in Children During Cast Removal using Oscillating Saw versus Cast Shear - A Randomised, Prospective Trial.

INTRODUCTION: To compare the anxiety levels demonstrated by children during cast removal procedure between oscillating saw vs cast shear methods. MATERIAL AND METHODS: A randomised prospective study of 102 children (mean age 8.3 ± 3.5 years) with fractures involving upper or lower limbs. Children undergoing removal of cast were divided into 2 groups; either by an oscillating saw or a cast cutting shear. The level of anxiety was assessed by recording the heart rate with a portable fingertip pulse oximeter before, during and after removal of the cast. Objective assessment was performed by documenting the fear level on Children's Fear Scale (CFS). RESULTS: There was a significant increase in the heart rate of children during cast removal while using the oscillating saw compared to cast shear (p<0.05). The noise level produced by the saw exceeded 80 dB (mean 103.3 dB). The fear level was significantly lower in the cast shear group (p<0.05). CONCLUSION: The noise produced by the oscillating saw was associated with an increased anxiety level in children undergoing cast removal. Cast shear is a simple and inexpensive instrument that can be used for cast removal in overly anxious children.

Subcapital Femoral Neck Tension Stress Fracture - A Rare Injury in A Child: A Case Report.

Femoral neck stress fractures are rare in children. To the best of our knowledge, the tension type stress fracture has been reported only twice in the English language literature. We report on a five years follow-up of a 10-year-old boy with this injury which was initially missed. The fracture healed after screw fixation. We highlight the importance of considering stress fracture as a differential diagnosis in a child with chronic hip pain. A careful physical examination and the appropriate imaging will avoid missing the diagnosis.

Cubitus Valgus with Tardy Ulnar Nerve Palsy - Is Anterior Transposition of the Ulnar Nerve Always Necessary? A Case Report.

Tardy ulnar nerve palsy is a known complication of cubitus valgus. The options for treating the ulnar neuropathy include anterior nerve transposition or neurolysis. We report on an 11-year-old boy who had a tardy ulnar nerve palsy due to cubitus valgus resulting from a non-union of a lateral condyle fracture of the humerus. Anterior transposition of the ulnar nerve was not done after the closing wedge osteotomy of the distal humerus. The close wedge osteotomy relieved the tension on the nerve and not transposing the ulnar nerve anteriorly prevented an iatrogenic nerve injury. The patient had no restriction with activities of daily living at the six years follow-up although neurological recovery was incomplete.

Tibia vara and slipped upper femoral epiphysis: is there an association?

Tibia vara and slipped upper femoral epiphysis (SUFE) share a common risk factor, but their relationship is unclear. In both conditions, the patients are usually obese. To the best of our knowledge, there have been only two previous reports in the literature that have described the occurrence of tibia vara and SUFE in three patients. We report a child who was treated for bilateral tibia vara at the age of 3 years and subsequently developed a SUFE at the age of 13 years.

The Rubber Stopper: A Simple and Inexpensive Technique to Prevent Pin Tract Infection following Kirschner Wiring of Supracondylar Fractures of Humerus in Children.

Percutaneous pinning after closed reduction is commonly used to treat supracondylar fractures of the humerus in children. Minor pin tract infections frequently occur. The aim of this study was to prevent pin tract infections using a rubber stopper to reduce irritation of the skin against the Kirschner (K) wire following percutaneous pinning. Between July 2011 and June 2012, seventeen children with closed supracondylar fracture of the humerus of Gartland types 2 and 3 were treated with this technique. All patients were treated with closed reduction and percutaneous pinning and followed up prospectively. Only one patient, who was a hyperactive child, developed pin tract infection due to softening of the plaster slab. We found using the rubber stopper to be a simple and inexpensive method to reduce pin tract infections following percutaneous pinning.

Comparison of Chlorella vulgaris dressing and sodium alginate dressing: an experimental study in rats.

BACKGROUND AND AIMS: Chlorella vulgaris (CV) is a green microalgae enriched with nutrients, vitamins, minerals and chlorophyll. The aim of our study was to evaluate the potential wound healing effects of CV as a dressing while comparing it to sodium alginate dressing. MATERIALS AND METHODS: Fifteen Sprague-Dawley rats were divided into three groups consisting of control (normal-wound with no dressing), CV and sodium alginate dressings. Wound was created on the dorsal surface of rats using a 6-mm sterilized punch biopsy. The wounds were examined on days 3, 6, 9 and 12 for dryness, exudation, contraction, period of epithelialization, complete wound closure and scar formation. All rats were sacrificed on day 12 and the granulation tissue formed on the wound was excised for the histological examination using Hematoxylin and Eosin stain (H&E). RESULTS: The wound's size treated with CV dressing was significantly reduced (p<0.05) compared to the control and sodium alginate treated wounds. H&E staining showed that CV dressing minimized the formation of scar tissue during the healing process. Although there was no statistically significant difference in the complete wound closure and period of epithelialization among the groups, a significant difference was observed regarding the dryness, exudation and scar formation in the wound. CONCLUSION: CV extract can be used as an effective supplement for wound dressing.

Incidence of contrast-induced nephropathy in intensive care patients undergoing computerised tomography and prevalence of risk factors.

Computerised tomography (CT) with contrast is frequently used in intensive care. Contrast-induced nephropathy (CIN) is an important complication largely studied in stable cardiology patients and can lead to acute renal failure. The aim of this study was to determine the incidence of CIN in an intensive care unit (ICU) setting and describe the prevalence of associated risk factors. We performed a retrospective analysis by review of electronic laboratory database and manual chart review of all patients in two tertiary intensive care units in Newcastle, New South Wales who underwent CT with intravenous contrast during their ICU stay in 2006. CIN was defined as an absolute increment in serum creatinine of 44.2 micromol/l or a relative increment of 25% from baseline at 48 to 72 hours following intravenous contrast. Patients' demographic, biochemical and contrast media data, physiological parameters, fluid and drug administrations and previously described as well as ICU specific risk factors were analysed. We compared CIN positive and CIN negative patients to identify risk factors associated with CIN. In total, 2043 patients were admitted to ICU during 2006 and 509 CT studies were performed. One hundred and forty-one of these included administration of intravenous contrast and 139 charts were reviewed. Sixteen out of 139 patients developed CIN (11.5%). More than 70% of patients had two or more risk factors. Age was the only risk factor found to be significantly associated with the development of CIN in a multivariate analysis (P value 0.04, OR 1.041, 95% confidence interval 1.002 to 1.081). Mortality was higher in CIN positive patients (31 vs 13%, P value 0.068). ICU and hospital length of stay was not significantly different in CIN positive and negative patients and persisting renal impairment was not found in CIN positive survivors. Based on this study, we cannot predict who will develop CIN in ICU using the described risk factors. Further prospective studies are needed to evaluate the incidence and outcomes of CIN in an ICU setting.

Campylobacter jejuni enterocolitis in neonates.

Campylobacter jejuni is one of the leading bacterial pathogens causing acute gastroenteritis in children. Only a few cases have been described in the world literature about neonatal enterocolitis due to campylobacter and none from Saudi Arabia. We describe six cases of neonatal enterocolitis due to this organism isolated during the period from September 1989 - January 1991 at Suleimania Children's Hospital, Riyadh, Saudi Arabia. All of the patients presented with diarrhea; duration ranging from 1-20 days. Three patients had blood and two had mucus in their stool. In contrast to the findings of other investigators, five neonates presented with fever. One neonate was treated with erythromycin, another received augmentin, and two received other antibiotics because of suspected sepsis. In one patient, previous antibiotics were discontinued and erythromycin was added and two received no antibiotics. Campylobacter infection should be suspected in any neonate presenting with diarrhea accompanied by mucus and blood in the stool.